Managed care explained

What is managed care?

Most Apple Health clients have “managed care,” which means Apple Health pays a health plan a monthly premium for your coverage, which include preventive, primary, specialty, and other health services. Clients in managed care must see only providers who are in their plan's provider network, unless prior authorized or to treat urgent or emergent care.

Changes to Apple Health managed care

Health Care Authority implemented changes to the Apple Health managed care program. You may learn more about these changes below.

Integrated Managed Care (IMC) coordinates physical health, mental health, and substance use disorder treatment services to help provide whole-person care under one health plan. By January 1, 2020, integrated managed care will be available in all regions.

Integrated managed care implementation began in 2016 with the Southwest Washington region (Clark and Skamania counties), and expanded in 2018 to the North Central region (Chelan, Douglas, and Grant counties).

Apple Health offers Behavioral Health Services Only (BHSO) plans in all regions with integrated managed care. These plans are for clients who are eligible for Apple Health, but not eligible for managed care enrollment, such as:

Dual-eligible – Medicare/Medicaid

Medically Needy

Clients who have met their spenddown

The Behavioral Health Services Only plans are offered by the same health plans administering Integrated Managed Care.

Upon becoming eligible for Apple Health coverage without a managed care plan (also known as fee-for-service), clients may select a Behavioral Health Services Only plan. For clients who do not select a plan, HCA will automatically enroll them into a BHSO plan. A BHSO fact sheet is available online.

Within available funding, a BH-ASO also has the discretion to provide outpatient behavioral health services or voluntary psychiatric inpatient hospitalizations for individuals who are not eligible for or enrolled in Apple Health. A BH-ASO fact sheet is available online.

Apple Health children in foster care (out of home placement) are auto-enrolled to Coordinated Care of Washington.

Adoption support and alumni have the ability to opt out of managed care for their physical health coverage with a phone call to the foster care unit at 1-800-562-3022 ext. 15480.

If you decide to receive your physical health coverage through the Apple Health coverage without a managed care plan, you will have the option to select a managed care plan for your behavioral health services.

In an integrated region: A list of the available Behavioral Health Services Only plans in the integrated managed care regions can be found in the Apple Health managed care plans available section. The same plans offering integrated managed care plans in each county also offers a Behavioral Health Services Only plan.

In a not yet integrated region: If you have the option to receive your physical health coverage without a managed care plan in a region that has not implemented integrated managed care yet, you will receive your behavioral health services through a Behavioral Health Organization in the following areas only:

Earlier enrollment (4/1/2016)

Newly eligible Medicaid clients and renewing clients choose or are auto-assigned into a managed care organization (MCO) the day they become eligible. Their managed care enrollment is backdated to the beginning of the current month. The intent of the change is to close the fee-for-service (FFS) gap between eligibility and enrollment. This change decreases the time on FFS with quicker health care coordination. Instead of having to wait a month or possibly two months before being enrolled, the client enrolls with the plan on the first day of the month that they became eligible.

Apple Health (Medicaid) and other primary health insurance (1/1/2017)

If you or someone in your household has Apple Health (Medicaid) coverage in addition to primary private health insurance (such as Kaiser Permanente or Blue Shield), changes were made to how the Washington State Health Care Authority (HCA) provides your Apple Health coverage.

On January 1, 2017, the agency began enrolling most fee-for-service Apple Health clients who have other primary health insurance into an agency-contracted managed care organization (MCO).

What is the difference in the plans?

All Apple Health plans cover the same basic services, but they have some differences in the way they provide services. Each health plan has its own network of providers, hospitals, and pharmacies. Please verify with the health plan that the providers you prefer are in the plan’s network.

What is fee-for-service (FFS)?

Some services are paid "fee-for-service (FFS)." That’s what we call it when Apple Health pays providers directly for each service they do, using the ProviderOne payment system.

Most Apple Health clients don’t get FFS for their regular health care, but this type of coverage is sometimes necessary due to the way other coverage works with Medicaid (Apple Health) — for instance, when clients have Medicare as their primary coverage. In some situations, clients are able to choose whether they receive FFS coverage or are enrolled in a health plan.

Regardless whether you are in a health plan or not, the following services are always covered fee-for-service (FFS).

Dental care

Vision hardware (children only)

Long-term care

Inpatient psychiatric care for physician services.

Your primary care provider or health plan will help you find these benefits and coordinate your care, when necessary.

Crisis services

24-hour crisis line

Statewide

Crisis services are available to support you, based on where you live.